- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,046.04 / $2,046.04 / $3,478.27
| Facility | | $2,046.04 | $2,046.04 | $3,478.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,020.78 / $2,046.04 / $2,096.56
| Professional | | $2,020.78 | $2,046.04 | $2,096.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $2,147.08
| Facility | | $2,147.08 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $2,147.08
| Professional | | $2,147.08 | $2,147.08 | $2,147.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $772.64 / $2,145.75 / $3,479.54
| Facility | | $772.64 | $2,145.75 | $3,479.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.98 / $2,104.98 / $2,580.71
| Professional | | $2,104.98 | $2,104.98 | $2,580.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.98 / $2,104.98 / $2,231.28
| Professional | | $2,104.98 | $2,104.98 | $2,231.28 |